Healthcare Provider Details

I. General information

NPI: 1356706246
Provider Name (Legal Business Name): AUSTIN SPECIAL CHICAGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2015
Last Update Date: 12/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5318 N ELSTON AVE
CHICAGO IL
60630-1611
US

IV. Provider business mailing address

5318 N ELSTON AVE
CHICAGO IL
60630-1611
US

V. Phone/Fax

Practice location:
  • Phone: 773-282-9992
  • Fax: 773-282-1749
Mailing address:
  • Phone: 773-282-9992
  • Fax: 773-282-1749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number199700018C
License Number StateIL

VIII. Authorized Official

Name: MRS. MARICEL R ABAN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 773-282-9992